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Annual Smoking-Attributable Mortality, Years of Potential Life Lost,
and Productivity Losses --- United States, 1997--2001

Smoking harms nearly every organ of the body, causing many diseases and reducing quality of life and life expectancy
(1). This report assesses the health consequences and productivity losses attributable to smoking in the United States during 1997--2001. CDC calculated national estimates of annual
smoking-attributable mortality (SAM), years of potential life lost (YPLL) for
adults and infants, and productivity losses for adults. The findings indicated that, during
1997--2001, cigarette smoking and exposure to tobacco smoke
resulted in approximately 438,000 premature deaths in the United States, 5.5 million YPLL, and $92 billion
in productivity losses annually. Implementation of comprehensive tobacco-control programs as recommended by CDC can
reduce smoking prevalence and related mortality and health-care costs
(1).

The Adult and Maternal and Child Health
Smoking-Attributable Mortality, Morbidity and Economic Cost
(SAMMEC) software (2) was revised on the basis of findings from the 2004 Surgeon General's report on diseases caused by smoking (1). The list of smoking-attributable diseases now includes stomach cancer and acute myeloid leukemia and
excludes hypertension. Sex- and age-specific
smoking-attributable deaths were calculated by multiplying the total number of deaths for 19 adult
and four infant disease categories by estimates of the smoking-attributable fraction (SAF) of preventable deaths. The
attributable fractions provide estimates of the public health burden of each risk factor and the relative importance of risk factors for multifactorial diseases. Because of the effect of interactions between various risk factors, attributable fractions for a
given disease can add up to more than 100%. For adults, SAFs were derived by using sex-specific relative risk (RR) estimates (2) for current and former smokers for each cause of death from the American Cancer Society's Cancer Prevention Study-II (CPS-II) for the period 1982--1988 (2). For ischemic heart disease and
cerebrovascular disease deaths, RR estimates were also
stratified by age (35--64 years and >65 years). SAFs also used sex- and age-specific (35--64 years and
>65 years) current and former cigarette smoking--prevalence estimates from the National Health Interview Survey.* For infants, SAFs were calculated by using pediatric RR estimates (2) and maternal smoking prevalence estimates from birth certificates
(2). Smoking-attributable YPLL and productivity losses were estimated by multiplying sex- and age-specific SAM by remaining life expectancy
(3) and lifetime earnings data (4). In addition,
smoking-attributable fire-related deaths (5) and lung cancer and heart disease
deaths attributable to exposure to secondhand smoke
(6,7) were included in the SAM estimates.

During 1997--2001, smoking resulted in an estimated annual average of 259,494 deaths among men and 178,408
deaths among women in the United States (Table). Among adults, 158,529 (39.8%) of these deaths were attributed to
cancer, 137,979 (34.7%) to cardiovascular diseases, and 101,454 (25.5%) to respiratory diseases. The three leading specific causes
of smoking-attributable death were lung cancer (123,836), chronic obstructive pulmonary disease
(COPD) (90,582), and ischemic heart disease (86,801). Smoking during pregnancy resulted in an estimated 910
infant deaths annually during 1997--2001. An estimated 38,112 lung cancer and heart disease deaths annually were attributable to exposure to secondhand smoke. The average annual SAM estimates also included 918 deaths from
smoking-attributable fires.

During 1997--2001, on average, smoking accounted for an estimated 3.3 million YPLL for men and 2.2 million YPLL
for women annually, excluding burn deaths and adult deaths from secondhand smoke. Estimates for average annual smoking-attributable productivity losses were approximately $61.9 billion for men and $30.5 billion for women during this period (Table).

Editorial Note:

During 1997--2001, an estimated 438,000
persons in the United States died prematurely each year as a
result of smoking or exposure to secondhand smoke. This figure is lower than the average annual estimate of approximately
440,000 deaths during 1995--1999 (8) because of changes in the list of smoking-attributable diseases and declines in the prevalence
of smoking. Accelerated reductions in the prevalence of smoking could prevent millions of premature deaths
(1).

The findings in this report are subject to at least six limitations. First, the estimates understate deaths attributable to tobacco use because estimates of deaths attributable to cigar smoking, pipe smoking, and smokeless tobacco use were
excluded. Second, RRs were based on deaths during 1982--1988
among birth cohorts who might have had different smoking
histories than current or former smokers (e.g., age of initiation and duration of smoking before quitting). Third, this report used
a death certificate--based definition of COPD, including codes for bronchitis/emphysema and chronic airway
obstruction
(ICD-10 J44) (1). Therefore, the COPD SAM estimate used for this report might differ from other estimates that use
other definitions of COPD (1). Fourth, RRs were adjusted for the effects of age but not for other
potential confounders. However, research suggests that education, alcohol, and other confounders had negligible additional impact on SAM estimates for lung cancer, COPD, ischemic heart disease, and cerebrovascular disease in CPS-II
(2). Fifth, productivity losses understate the
total costs of smoking because costs associated with smoking-attributable health-care expenditures,
smoking-related disability, employee absenteeism, and secondhand smoke--attributable disease morbidity and mortality were not included. Finally,
the estimates do not account for the sampling variability in smoking prevalence estimates or in RRs.

Cigarette smoking continues to impose substantial health and financial costs on society. In 1998, smoking-attributable health-care expenditures were estimated at $75.5 billion
(2). During 1997--2001, these expenditures plus the
productivity losses ($92 billion) exceeded $167 billion per year. By comparison, investments in comprehensive, state-based
tobacco prevention and control programs in 2002 were approximately 200-fold smaller than those costs
(9). Because investments in evidence-based prevention programs have produced larger and faster reductions in cigarette consumption
(10), increased investments to the levels recommended by CDC are needed to achieve a greater health impact.

References

CDC. The health consequences of smoking: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human
Services, CDC; 2004.

* SAFs for each disease are calculated by using the following equation: SAF =
[(p1(RR1 -- 1) +
p2(RR2 -- 1)] / [ p1(RR1 -- 1) + p2(RR2 -- 1) + 1] where
p1 = percentage of current smokers (persons who have smoked >100 cigarettes and now smoke every day or some days), p2 = percentage of former smokers
(persons who have smoked >100 cigarettes and do not currently smoke), RR1 = relative risk for current smokers relative to never smokers, and RR2 = relative risk for former smokers relative to never smokers.

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